Prescription Refill | UH Specialty Pharmacy | Department of Pharmacy Services | University Hospitals | Cleveland, OH

Please complete this form to request a prescription refill from UH Specialty Pharmacy.

First Name

Last Name

Date of Birth

Email Address

Telephone

Confirmation of no change in address since last refill

Prescription name(s) or Rx Number(s)

Have you been ill or hospitalized in the past 30 days or have you had any changes to your medication?

No

Yes

Are you taking your medication as directed?

No

Yes

Changes to Allergies? If yes, please explain:

Changes to Medications? If yes, please explain:

New conditions since last clinic visit? If yes, please list:

Questions or concerns for the pharmacist?

Date delivery requested

Do you agree to leave package without a signature?

No

Yes

I agree to have my co-pay invoiced.

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